Tele-rheumatology reaches patients who lack access to care
Is tele-rheumatology right for all settings?
But tele-rheumatology may not be appropriate in all practice settings or the right method for all rheumatology patients, doctors say.
As the Dartmouth-Hitchcock study noted, patients with complex diseases or unclear underlying conditions do not make good telemedicine patients. In addition, opinions are mixed about whether physicians and patients should have an established relationship before telemedicine visits occur and what such visits should entail.
Anchorage, Alaska-based rheumatologist Elizabeth Ferucci, MD, uses telemedicine only for follow up. Like many rheumatologists in Alaska, she travels to field clinics in larger communities throughout the state twice a year to treat patients, said Dr. Ferucci, a rheumatologist for the Alaska Native Tribal Health Consortium. Because some patients need to be seen more than twice a year, Dr. Ferucci conducts follow-up visits every 2-3 months via video.
However, Dr. Ferucci notes that having a trained telemedicine presenter capable of performing a joint examination in the room with the patient is not always possible because of high staff turnover and the more than 200 villages served. A nurse or staff member remains in the room with the patient, but they are not always trained to perform joint exams.
At Dartmouth-Hitchcock, Dr. Albert’s practice accepts both initial and follow-up patient visits. He acknowledges that tele-rheumatology is best used for follow-up care, but explains that limiting the center’s telemedicine use would leave some patients without treatment.
“Because the constraints of getting to Dartmouth are so great, we don’t want to impose that restriction on patients,” Dr. Albert said. “However, in general, it is preferable to do an in-person consultation first to clarify the physical findings.”
Dartmouth has used both nurses and medical assistants as presenters during tele-rheumatology after developing a web-based video series to train presenters. Nurses at UPMC are also trained as telemedicine presenters, and telemedicine visits are only used for follow-up care, Dr. Peoples said.
At Children’s Mercy in Kansas City, telemedicine visits are restricted to follow-up care and include a nurse facilitator at the virtual site. However, the type of conditions and stages of disease examined through the technology has grown since the telemedicine services started, Dr. Kessler said.
“What we feel comfortable seeing has expanded since the time we initially started the clinic because some of the patients, when they were having flares, could not come to Kansas City for financial reasons,” she said, adding that she has since examined children with lupus, vasculitis, and active arthritis through telemedicine.
She stresses that in-person visits should depend on the patient, the circumstances, and the physician’s comfort level. ”You need to be realistic,” she said. “There are times when I’ve said to families, ‘I would like you to come to Kansas City because I’m a little unsure about your exam findings.’ There are definitely some patients who do more of a hybrid approach where they come to Kansas City and are also seen by telemedicine.”
Barriers slow telemedicine progress
Amid its benefits, challenges for tele-rheumatology, such as reimbursement and licensure obstacles, remain.
Commercial insurers pay for telemedicine at varying rates, making it difficult for doctors to consistently be paid, Dr. Peoples said.
“A lot of insurance companies do cover telemedicine visits, but still, a lot don’t,” she said. “I do think that in order to remain competitive, insurance companies overall are going to have to start covering these services.”
At least 32 states and the District of Columbia have parity laws that require commercial health insurers to cover services provided through telehealth to the same extent as those services are covered in person, according to an Aug. 15, 2016 Health Affairs policy brief. However, how private insurers pay and what services they cover vary widely.
Medicaid reimbursement for telehealth depends on individual state Medicaid programs. Only 9 states Medicaid programs reimburse for store-and-forward services, while at least 16 states have some sort of Medicaid reimbursement for remote patient monitoring, according to the Health Affairs report.
Medicare payment for telehealth is clouded in restrictions. The Centers for Medicare & Medicaid Services reimburses for synchronous communications only and does not cover store-and-forward services or remote patient monitoring for chronic diseases, except in Alaska and Hawaii. The patient must be present at an originating site for the visit and cannot be home to receive the services. In addition, CMS reimburses for telehealth only when the originating site is in a Health Professional Shortage Area or within a county outside a Metropolitan Statistical Area. In 2016, CMS expanded its coverage of telehealth to include several new codes including, end-stage renal disease–related services for dialysis, advance care planning services, and critical care consultations furnished via telehealth using new Medicare G-codes.
It’s worth noting that rheumatologists who are salaried employees of academic medical centers, as is the case for all rheumatologists interviewed here, don’t handle the billing for their telemedicine services, and so have not experienced the payment challenges that smaller practices may face.
Mr. Linkous of the American Telemedicine Association said that he believes that reimbursement for telemedicine will improve as health care heads toward value-based payment systems.
“In terms of reimbursement, with the move away from fee-based systems to value-based systems, it really opens the door because for many of the services, you no longer write out a bill with a code associated with it,” he said. “You are paid on the basis of keeping people well. That’s a great positive incentive for using telemedicine.”
Differing state licensure requirements also pose a challenge. The process to obtain licenses and navigate varying credentialing processes can be a headache for health providers and delay approval.
The barrier has led to model legislation by the Federation of State Medical Boards (FSMB) that aims to make it easier for telemedicine physicians to gain licenses in multiple states. Under the Interstate Medical Licensure Compact, physicians designate a member state as the state of principal licensure and select the other states in which they want to license. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.
As of January, 18 states had enacted the compact legislation, and at least 4 states had introduced the legislation. In 2015, the Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.
